National Training Program

1. National Training Program Module 11 Medicare Advantage (MA) Plans and Other Medicare Plans

2. Session Objectives • This session will help you to • Define Medicare Advantage (MA) Plans • Describe how MA Plans work • Explain eligibility requirements and enrollment • Identify types of MA Plans • Identify other Medicare Plans • Recognize rights, protections, and appeals • Understand Medicare Marketing Guidelines Medicare Advantage Plans and Other Medicare Plans

3. Lesson 1 - Medicare Advantage Plan Overview • Define Medicare Advantage (MA) Plans • How Medicare Advantage Plans work • When you can join or switch plans • Types of Medicare Advantage Plans Medicare Advantage Plans and Other Medicare Plans

4. What is a Medicare Advantage Plan? • Health plan options • Approved by Medicare • Run by private companies • Part of the Medicare program • Sometimes called Part C • Available across the country • Provide Medicare-covered benefits • May cover extra benefits Medicare Advantage Plans and Other Medicare Plans

5. How Medicare Advantage Plans Work • Receive services through the plan • All Part A and Part B covered services • Some plans may provide additional benefits • Most plans include prescription drug coverage • You may have to visit network doctors/hospitals • May differ from Original Medicare • Benefits • Cost-sharing Medicare Advantage Plans and Other Medicare Plans

6. How Medicare Advantage Plans Work-Continued • You are still in Medicare program • Medicare pays the plan every month for your care • You still have Medicare rights and protections • If the plan leaves Medicare • You can join another Medicare Advantage Plan, or • You can return to Original Medicare Medicare Advantage Plans and Other Medicare Plans

7. Medicare Advantage Costs • You still pay the Part B premium • A few plans may pay all or part for you • State assistance for some • You pay plan an additional monthly premium • You pay deductibles, coinsurance, and copayments • Different from Original Medicare • Varies from plan to plan • Costs may be higher if out-of-network Medicare Advantage Plans and Other Medicare Plans

8. Who Can Join A Medicare Advantage Plan? • Eligibility requirements • Entitled to Medicare Part A (Hospital Insurance) • Enrolled in Medicare Part B (Medical Insurance) • Live in plan service area • Usually no End-Stage Renal Disease (ESRD) at enrollment • To join you must also • Provide necessary information to the plan • Follow the plan rules • Belong to one plan at a time Medicare Advantage Plans and Other Medicare Plans

9. Status of MA • As of September 2013, 15 million beneficiaries enrolled, or 29% of the Medicare population • ACA enacted several reductions in payments to MA • Premiums to be modestly higher in 2014, as will out-of-pocket limits • Choices remain stable, with 18 plans on average available to beneficiaries • 60 fewer plans in 2014, or 2014 plans • 5% will need to change plans

10. Status of MA • Premiums will rise from $35 to $39 for those who remain in their plan • New Entrants, Departing Plans, Effects on Beneficiaries • Special Needs Plans and MMP Demonstrations • Phased in payment reductions, MLR, Tax in 2014

11. Medicare Advantage Plans and Other Medicare Plans

12. Medicare Advantage Plans and Other Medicare Plans

13. Medicare Advantage Plans and Other Medicare Plans

14. Medicare Advantage Plans and Other Medicare Plans

15. Special Enrollment Period Trial Rights • People who join an MA Plan for the first time • When first eligible at 65 or • Leave Original Medicare and drop Medigap policy • Can disenroll during first 12 months • Return to Original Medicare • Have guaranteed issue rights for Medigap Medicare Advantage Plans and Other Medicare Plans

16. Types of Medicare Advantage Plans • Health Maintenance Organization (HMO) • HMO Point-of-Service Plan (HMOPOS) • Preferred Provider Organization (PPO) • Special Needs Plan (SNP) • Private Fee-for-Service (PFFS) • Medicare Medical Savings Account (MSA) Medicare Advantage Plans and Other Medicare Plans

19. Medicare Advantage Plans and Other Medicare Plans

20. Medicare Advantage Plans and Other Medicare Plans

22. Medicare Advantage Plans and Other Medicare Plans

23. PFFS Access Requirements • Employer PFFS Plans must meet access requirements • Plans may meet access requirements • Through a contracted network of providers • Where two or more network-based MA Plan options exist • Non-employer PFFS plans must meet access requirements through contracts with providers Medicare Advantage Plans and Other Medicare Plans

24. Less Common Medicare Advantage Plans • HMO Point of Service (HMOPOS) Plans • May allow out-of-network services • Medical Savings Account (MSA) Plans • Combine high deductible plan with bank account • Medicare deposits money into account • Use money to pay for services Medicare Advantage Plans and Other Medicare Plans

25. Medicare Advantage Plan NetworkChanges • Many types of MA plans have provider networks • Plans may change networks mid-year • Must notify beneficiaries who see affected providers • 30 days prior to termination • Must maintain adequate access to services • Must protect beneficiaries from interruptions in medical care • Mid-year network changes are not basis for SEP Medicare Advantage Plans and Other Medicare Plans

26. Check Your Knowledge – Lesson 1 • Medicare Advantage Plans are sometimes called: • Part A • Part B • Part C • Part D 2.George is currently enrolled in Original Medicare. In June, he decides he would like to enroll in a MA Plan with a 5-Star overall rating. Is he able to do so? • No, he is not eligible for a MA Plan • No, he must wait for the Open Enrollment Period (Oct. 7-Dec. 15) • Yes, only if he moved outside of his current plan’s service area • Yes, he can enroll in a 5-Star MA Plan at any time during the year. Medicare Advantage Plans and Other Medicare Plans

27. Lesson 2 - Other Medicare Plans • Medicare Cost Plans • Medicare Innovation Projects and Pilot Programs • PACE (Programs of All-Inclusive Care for the Elderly) Medicare Advantage Plans and Other Medicare Plans

28. Other Medicare Plans • Not part of Medicare Advantage • Still part of Medicare • Some provide Part A and/or Part B coverage • Some provide Part D coverage Medicare Advantage Plans and Other Medicare Plans

29. Medicare Cost Plans • Available in limited areas • Must have Part B to join • Can see a non-network provider • Services covered under Original Medicare • Join anytime new members being accepted • Leave any time and return to Original Medicare • Get Medicare prescription drug coverage • From the plan (if offered) • Join a separate Medicare prescription drug plan Medicare Advantage Plans and Other Medicare Plans

30. Innovation Projects and Pilot Programs • Special projects that test improvements in • Medicare coverage • Payment • Quality of care • Eligibility usually limited • Specific group of people or specific area of country • Examples of how they help shape Medicare • MA Plan for End-Stage Renal Disease patients • New Medicare preventive services Medicare Advantage Plans and Other Medicare Plans

31. Medicare PACE Plans • Programs of All-Inclusive Care for the Elderly • Combine services for frail elderly people • Medical, social, and long-term care services • Include prescription drug coverage • Alternative to nursing home care • Only in states that offer it under Medicaid • Qualifications vary from state to state • Contact state Medical Assistance office for information Medicare Advantage Plans and Other Medicare Plans

32. Check Your Knowledge – Lesson 2 • Linda participates in a Program of All-Inclusive Care for the Elderly (PACE). What kind of services are coordinated for her under PACE? • Prescription drug coverage • Medical services • Social Services • Transportation Services • All of the above Medicare Advantage Plans and Other Medicare Plans

33. Lesson 3 - Rights, Protections, and Appeals • Guaranteed Rights and Protections • Appeals • Required Notices Medicare Advantage Plans and Other Medicare Plans

34. Guaranteed Rights • To get needed health care services • To receive easy-to-understand information • To have personal medical information kept private Medicare Advantage Plans and Other Medicare Plans

35. Rights in Medicare Health Plans • Choice of health care providers • Access to health care providers (treatment plan) • Know how your doctors are paid • Fair, efficient, and timely appeals process • Grievance process • Coverage/payment information before service • Privacy of personal health information Medicare Advantage Plans and Other Medicare Plans

36. Appeals in Medicare Advantage Plans • Plan must say in writing how to appeal if it • Will not pay for a service • Does not allow a service • Stops or reduces course of treatment • Can ask for expedited (fast) decision • Plan must decide within 72 hours • See plan membership materials • Instructions on how to file an appeal or grievance Medicare Advantage Plans and Other Medicare Plans

37. Medicare Part C Appeals Process Initial Decision Plan Reconsideration Independent Review Entity (IRE) Administrative Law Judge (ALJ) Medicare Appeals Council (MAC) Judicial Review * * * * *These pre-service timeframes include a possible extension of up to 14 days Medicare Advantage Plans and Other Medicare Plans

38. Medicare Health Plan Fast Appeals Process • Notice of Medicare Non-Coverage • Provider must deliver at least 2 days before care will end • If you think services are ending too soon • Contact your Quality Improvement Organization (QIO) • QIO must notify you of its decision • COB the day after it receives all necessary information Medicare Advantage Plans and Other Medicare Plans

39. Inpatient Hospital Appeals • Provider/plan must provide Notice of Discharge and Medicare Appeal Rights (NODMAR) • At least the day before services end if • You disagree with discharge decision • Provider/plan lowers your care level • Appeal to QIO by noon of first day after NODMAR • Decision from QIO usually within 2 days • You remain in hospital • Incur no financial liability until QIO gives decision Medicare Advantage Plans and Other Medicare Plans

40. Rights if You File an Appeal with Your Medicare Health Plan • Right to get your files from the plan • Call or write your plan • Plan may charge a fee Medicare Advantage Plans and Other Medicare Plans

41. Check Your Knowledge – Lesson 3 Who do you need to contact if you think services for home health care are ending to soon? • State Health Insurance and Assistance Program (SHIP) • Quality Improvement Organization (QIO) • Social Security • Home Health Agency Medicare Advantage Plans and Other Medicare Plans

42. Lesson 4 -Medicare Parts C and D Marketing • Medicare Marketing Guidelines • Key updates • Promotional activity reminders • Agent information • Marketing surveillance Medicare Advantage Plans and Other Medicare Plans

43. Medicare Marketing Guidelines (MMG) • Policy clarifications and operational guidance • Updated each year • 2013 MMG released in June 2012 • CMS marketing requirements apply to • Medicare Advantage Plans • Medicare Prescription Drug Plans • Cost Plans • Some other plans Medicare Advantage Plans and Other Medicare Plans

44. Marketing Materials • CMS reviews marketing materials • Exceptions are listed in Section 20 of the MMG • CMS may review and approve any materials • Retains the right to review/approve as needed • CMS creates standardized model marketing materials Medicare Advantage Plans and Other Medicare Plans

45. Marketing Updates • Plan star ratings • Individual measures • Overall performance rating • Multi-Language Insert (MLI) • Must provide with certain materials • Summary of Benefits (SB) • Annual Notice of Change (ANOC) • Evidence of Coverage (EOC) Medicare Advantage Plans and Other Medicare Plans

46. Disclosure of Plan Information for New and Renewing Members • MA and PDPs must disclose plan information • At time of enrollment and at least annually • Required Annual Notice of Change/Evidence of Coverage • Comprehensive or abridged formulary • Member ID card at the time of enrollment/as needed • At time of enrollment and at least every three years after • Pharmacy directory • Provider directory Medicare Advantage Plans and Other Medicare Plans

47. Nominal Gift Reminders • Nominal gifts • Organizations can offer gifts to potential enrollees • Must be of nominal value • Defined in Medicare Marketing Guidelines • Currently $15 or less based on retail value • Given regardless of beneficiary enrollment Medicare Advantage Plans and Other Medicare Plans

48. Unsolicited Beneficiary Contact • UnsolicitedContacts • Extends existing door-to-door prohibition • Outbound marketing calls • Common areas • Calls/visits after attending sales event • Unless express permission given • Unsolicited emails Medicare Advantage Plans and Other Medicare Plans

49. Cross Selling Prohibition • Cross selling • Prohibited during any MA or Part D sales activity/presentation • Cannot market non-health related products • Annuities • Life insurance • Other products • Allowed on inbound calls per request Medicare Advantage Plans and Other Medicare Plans

50. Scope of Appointment Reminders • Scope of Appointment • Must specify product type • MA, PDP, Medigap, or other • Prior to marketing and/or in-home appointment • Additional products can only be discussed • On beneficiary request • At separate appointment Medicare Advantage Plans and Other Medicare Plans